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Figure 10-4. Osteology of the medial side of the foot and ankle.
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Figure 10-5. The anatomy of the superficial structures of the anterior portion of
the ankle and the dorsum of the foot. At the level of the ankle joint, the
neurovascular bundle lies immediately lateral to the extensor hallucis longus
tendon.
Landmarks
Bony Structures of the Ankle
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The dome of the talus and the inferior articular surface of the tibia form the
articulation that bears weight in the ankle. The joint itself is stabilized by
the medial and lateral malleoli, the bony landmarks of the area. The medial
malleolus is both shorter and more anterior. It remains in contact with the
medial side of the talus throughout the range of motion (see Figs. 10.3 and
10-4).
The configuration of the malleoli causes the ankle mortise to point 15
degrees laterally. During dorsiflexion, the widest portion of the talus (the
anterior portion) is in the ankle mortise, forcing the mortise itself to widen.
The mortise narrows to accommodate the narrower part of the talus during
plantar flexion. Hence, if an ankle must be immobilized, it must be put in
the functional position, that is, foot flat position (see Figs. 10-4, 10-7, 10-
10, and 25.3). Note also that, if a screw or flexible fixation is inserted
between the fibula and the tibia (as in the reconstruction of a diastasis), that
fixation should be inserted with the ankle placed in maximal dorsiflexion.
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Figure 10-6. The extensor tendons have been resected to reveal the ligaments
of the anterior portion of the ankle joint and the joints of the middle part of the
foot.
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Figure 10-7. Osteology of the anterior part of the ankle joint and middle part of
the foot.
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Figure 10-8. The superficial anatomy of the lateral and dorsolateral aspects of
the foot and ankle. The peroneal tendons are held in place by their superior and
inferior retinacula.
Medial Approaches to the Ankle
Two groups of flexor tendons lie on the medial side of the ankle:
1. Three plantar flexors of the ankle and foot insert into the plantar surface
of the foot and are supplied by the tibial nerve. Their positions behind the
medial malleolus are remembered best in the form of the mnemonic
“Tom, Dick, and Harry.” The tibialis posterior is closest to the medial
malleolus; the flexor digitorum longus is behind it; and the flexor hallucis
longus is the most posterior and lateral of the three. A second mnemonic
is “Tom Drives A Very Nervous Horse”; it points out that the posterior
tibial vessels and tibial nerve lie between the flexor digitorum longus and
flexor hallucis longus muscles (see Figs. 10-1 and 10-2). All three
muscles are supplied by the tibial nerve.
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2. The three muscles that insert into the posterosuperior part of the os calcis
(the gastrocnemius, soleus, and plantaris) do so via their common Achilles
tendon. Supplied by the tibial nerve, they are the most powerful plantar
flexors of the ankle. Since they insert more to the medial side of the
posterior surface of the calcaneum than to the lateral side, they also invert
the heel.
The Achilles tendon inserts into the middle-third of the posterior surface
of the calcaneum. The collagen fibers that comprise the tendon rotate about
90 degrees around its longitudinal axis, between its origin and its insertion
onto bone. Viewed from behind, the rotation is in a medial-to-lateral
direction. Thus, fibers that begin on the medial side of the tendon lie
posteriorly, and those that begin on the lateral side lie anteriorly at the level
of the insertion. This anatomic fact makes it possible to lengthen the
Achilles tendon by dividing its anterior two-thirds near the insertion and its
medial two-thirds 5 cm more proximally. Dorsiflexion of the foot lengthens
the tendon, and no suture is required. The operation can be done either as an
open or as a subcutaneous procedure.5 This arrangement of the fibers can be
remembered by thinking of this tendon lengthening as the “DAMP
operation,” which stands for distal anterior medial proximal.
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Figure 10-9. The peroneal and extensor tendons have been resected to reveal
the ligaments of the lateral and anterolateral ankle joints. Note the peroneal
tubercle and the resected portion of the inferior peroneal retinaculum, which
forms separate fibro-osseous tunnels for the peroneal tendons. The
calcaneofibular ligament is visible deep to the superior peroneal retinaculum.
A fat pad lies between the Achilles tendon and the bone, with a bursa
that may become inflamed.6 A second bursa exists between the insertion of
the tendon into the os calcis and the skin (see Fig. 10-1).
The flexor retinaculum is a thickening of the fascia that stretches from
the medial malleolus to the back of the calcaneum. It covers the three flexor
tendons that pass around the back of the medial malleolus, as well as the
neurovascular bundle.
The tibial nerve may be trapped by this retinaculum, producing pain and
paresthesia in the distribution of the medial and lateral plantar nerves and
their calcaneal branches. The syndrome is known as the tarsal tunnel
syndrome (see Fig. 10-1). The exact nature of the pathology is unclear, as
are treatment options.
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The anterior and posterior approaches to the medial malleolus and the
medial approach to the ankle with osteotomy of the medial malleolus are
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essentially direct approaches onto a subcutaneous bone and do not use an
internervous plane.
The posteromedial approach to the ankle utilizes the intermuscular plane
between the Achilles tendon and the flexor tendons that run behind the
medial malleolus. This is not an internervous plane but is safe because the
muscles concerned receive their nerve supply well proximal to the
approach.
Anterior Approach to the Ankle
Extensor Muscles
Four muscles cross the anterior aspect of the ankle joint. All are extensors
of the ankle and are supplied by the deep peroneal nerve. The muscles, from
medial to lateral, are the tibialis anterior, extensor hallucis longus, extensor
digitorum longus, and peroneus tertius. The neurovascular bundle crosses
the front of the ankle virtually under the tendon of the extensor hallucis
longus (see Fig. 10-5).
Extensor Retinacula
The superior extensor retinaculum is a thickening of the deep fascia above
the ankle. It runs between the tibia and the fibula and is split by the tendon
of the tibialis anterior muscle, which lies in a synovial sheath just above the
ankle (see Fig. 10-5).
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The inferior extensor retinaculum, on the dorsum of the foot, is attached
to the lateral side of the upper surface of the os calcis. The retinaculum is
split medially; the upper part attaches to the medial malleolus, whereas the
lower part travels across the foot, where it sometimes joins the plantar
aponeurosis in the sole. The two retinacula prevent the anterior tendons
from bowstringing; they should be repaired after any approach that cuts
them (see Fig. 10-5).
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Figure 10-10. Osteology of the lateral side of the foot and ankle.
Anterior approaches to the ankle utilize intermuscular planes between
the extensor muscle tendons; the plane used depends on the surgery to be
performed. The interval between extensor hallucis longus and extensor
digitorum longus allows access to the entire ankle joint but does contain the
neurovascular bundle. Other intermuscular intervals can be used to access
specific portions of the distal tibia and are useful in pilon fracture surgery.
The anterior neurovascular bundle is the key anatomic structure in ankle
arthroscopy. The bundle should be identified and marked before a
tourniquet is applied to ensure it is not damaged during insertion of the
arthroscope or arthroscopic instruments.
Lateral Approaches to the Ankle
The tendons of the peroneal muscles pass behind the lateral malleolus to
reach the foot. Both evert the foot and are supplied by the superficial
peroneal nerve (see Fig. 10-8).
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